A revised AAP policy statement does not recommend routine circumcision for newborn males, but it does say current evidence indicates the health benefits of the procedure outweigh the risks.

The previous circumcision policy statement in 1999 — reaffirmed in 2005 — said there was not enough evidence for a recommendation either way. Since then, however, numerous studies suggest newborn circumcision can reduce the risk of urinary tract infections (UTIs), penile cancer and some sexually transmitted infections (STIs), including heterosexually acquired HIV, syphilis, herpes and human papillomavirus (HPV).

“This is a field that has changed quite a bit in the last 10 years,” said Douglas S. Diekema, M.D., FAAP, a member of the AAP Task Force on Circumcision and a bioethics expert. “In 1999, there was some data suggesting that there were some small medical benefits to circumcision but, at the time, there was not a compelling medical reason to recommend circumcision. So the previous policy didn’t argue for or against circumcision. However, now there is much stronger evidence about protective medical benefits associated with circumcision, so the tone of this policy statement has changed.”

Dr. Diekema

Like last time, the policy statement indicates that it is important for physicians to regularly inform parents in an unbiased manner about the health benefits and risks of circumcision, leaving the decision about whether to circumcise up to the parents. Cultural, religious and ethical beliefs and practices may play a part in parents’ decision about what is in the best interest of their child, according to the Circumcision Policy Statement (Pediatrics. 2012;130:585-586; http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2012-1989), which also has been endorsed by the American College of Obstetricians and Gynecologists.

“Pediatricians should remain nonjudgmental and support the choice that parents make,” said Dr. Diekema.

Circumcisions should be performed by trained and competent providers in a sterile environment using adequate pain management, the policy says, noting that nonpharmacologic techniques alone are insufficient.

Systematic approach

In 2007, the Academy formed the Task Force on Circumcision to review data and update the policy statement. The task force consists of experts in the fields of primary care and subspecialty pediatrics, including neonatology, general pediatrics, infectious diseases, anesthesiology, urology, bioethics, epidemiology and child health care financing, as well as representatives from obstetrics and gynecology, and family practice.

According to task force Chair Susan Blank, M.D., M.P.H., FAAP, the group defined the subject areas to be addressed in the policy statement, developed criteria for searching the literature and reviewed the yield in order to include only scientific studies. Each task force member was charged with reviewing some of the 1,000 studies published between 1995 and 2010 that eventually were used to develop the policy statement and accompanying Technical Report: Male Circumcision (Pediatrics. 2012;130:e756-785; http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2012-1990).

Dr. Blank

What the data revealed

Some of the most significant findings were discovered in studies devoted to the link between circumcision and HIV prevention. According to research, the protective effects of circumcision reduced the incidence of heterosexually transmitted HIV by 40% to 60% in Africa where this type of HIV is prevalent.

Circumcised males had a much lower risk of UTIs in the first year of life.

Although significant data point toward the protective health benefits of circumcision, experts were unable to find any evidence indicating that circumcision negatively affects sexual function or sensitivity as many circumcision critics claim. In fact, several studies with men circumcised as adults suggest the opposite, with many study participants indicating either greater or the same sexual satisfaction and sensation.

Access, coverage, other concerns

Surveys show that circumcision rates range from 42% to 80% nationwide, depending on the population. In addition, several surveys report that the number of newborn males being circumcised decreased from about 63% in 1999 (when the Academy released its earlier policy) to about 57% in 2008.

Dr. Diekema said insurance coverage for circumcision also decreased after the Academy’s 1999 policy statement was released. As of 2009, 15 states did not provide Medicaid payment for circumcision, and two other states had variable coverage, according to the technical report.

Parents whose children were not circumcised as newborns may question pediatricians about the new information.

“It is possible that some parents will look at the new information and feel they didn’t have adequate information when they made their decision, but I don’t think there will be a significant increase in older children getting circumcised,” said Michael T. Brady, M.D., FAAP, task force member and chair of the AAP Committee on Infectious Diseases.

Dr. Brady

One of the major reasons circumcision is performed during the newborn period is that it provides protection against UTIs, which are most likely to occur during the first year of life, according to the technical report. In addition, the likelihood of circumcision complications rises as children get older, from less than 1% during the newborn period to 1.1% to 9% in non-newborns. The most common risks for both newborns and non-newborns are bleeding and infection.

The technical report also includes information about the care of the circumcised vs. uncircumcised penis, analgesia and anesthesia methods, and areas for future research.

“The onus is going to be placed on providers to be more proactive about explaining the benefits and risks of circumcision,” said Dr. Brady, “because to not provide that information would not be good practice.”

Resources

Access the updated parent brochure, Circumcision: Information for Parents at HealthyChildren.org. The brochure also is available in packs of 50 through the AAP Bookstore, http://tinyurl.aap.org/pub39150.

For speaking points to prepare for media interviews on circumcision, members can login to MyAAP, www.aap.org/moc.

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